Healthcare Provider Details

I. General information

NPI: 1588703813
Provider Name (Legal Business Name): NICOLAS CARRASCO PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 E HIGHLAND MALL BLVD STE 252
AUSTIN TX
78752-3766
US

IV. Provider business mailing address

502 COQUINA LN
WEST LAKE HILLS TX
78746-4503
US

V. Phone/Fax

Practice location:
  • Phone: 512-845-7105
  • Fax:
Mailing address:
  • Phone: 512-845-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number9434
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number24685
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: